Laparoscopic v open donor nephrectomy for pediatric kidney recipients: preliminary report of a randomized controlled trial.

BACKGROUND AND PURPOSE: Laparoscopic surgery is widely accepted for nephrectomy in adult renal transplantation. The success of this technique has not been compared with open donor nephrectomy (ODN) in children. PATIENTS AND METHODS: In this randomized clinical trial, 40 adult kidney donors were randomly divided into two groups: 20 cases of laparoscopic donor nephrectomy (LDN) and 20 of ODN. Recipients had an age of <15 years. Our exclusion criteria were previous renal transplantation, hemolytic uremic syndrome, focal segmental glomerulosclerosis, oxalosis in the recipients, and multiple renal arteries bilaterally in donors. RESULTS: All donor nephrectomies were completed as scheduled, and no patients undergoing LDN required conversion to open nephrectomy. No patients in either the ODN or the LDN group required reoperation. Acute rejection was diagnosed in six patients receiving kidneys procured by ODN (30%) and 4 patients (20%) receiving kidneys obtained by LDN (P = 0.3). No recipients or donors died. At 1 year, the graft survival times in the ODN and LDN groups were 310.8 +/- 28.8 and 302.7 +/- 28.2 days, respectively (P = 0.8). CONCLUSION: At our medical center, pediatric LDN recipients had graft outcomes similar to those of ODN recipients. We recommend LDN for harvest of kidneys for pediatric recipients at experienced centers.

Laparoscopic pyeloplasty in secondary ureteropelvic junction obstruction after failed open surgery.

BACKGROUND AND PURPOSE: Laparoscopic pyeloplasty has been accepted as a helpful option for the treatment of primary ureteropelvic junction (UPJ) obstruction. We report the results of laparoscopic pyeloplasty in cases with secondary UPJ obstruction after failed open pyeloplasty. PATIENTS AND METHODS: Between September 2003 and March 2006, 18 patients with secondary UPJ obstruction secondary to failed open surgery who had undergone laparoscopic pyeloplasty using different techniques were enrolled in this study. The mean age and male-to-female ratio were 29.8 years (range 5-65 years) and 14: 4, respectively. Pain, fever, duration of the operation, changes in renal function, and rate of complications were reviewed. RESULTS: The mean operation time and average hospital stay were 254 +/- 82 minutes and 7.2 days (range 3-12 days), respectively. The mean follow-up was 14.1 months (range 4-25.5 months). No intraoperative complication occurred. Flank pain, urinary-tract infection, and severe hydronephrosis decreased from 88.9% to 22.2%, 33.3% to 0, and 83.3% to 16.6%, respectively. After laparoscopic pyeloplasty, 100% of patients had improvement in renal function. The number of patients with >50% washout on the DTPA scan 10 and 20 minutes after furosemide injection were 0 and 2 before the operation and 5 and 12 after the operation (27.8% and 62.5% increment, respectively). CONCLUSION: Laparoscopic pyeloplasty can be used with acceptable success rate in secondary UPJ obstruction in patients with previous open pyeloplasty.

Percutaneous nephrolithotomy of patients with staghorn stone and incidental purulent fluid suggestive of infection.

BACKGROUND AND PURPOSE: Patients undergoing percutaneous nephrolithotomy (PCNL) sometimes have purulent fluid in the puncture site in spite of having no signs or symptoms of infection preoperatively. We report the safety and effectiveness of PCNL in 45 patients with staghorn renal stones and incidental purulent fluid in the pelvicaliceal system. PATIENTS AND METHODS: Of 1264 patients who underwent PCNL at our medical center from February 2002 to May 2006, 45 patients had purulent fluid in the initial puncture. These patients were asymptomatic, and the preoperative work-up did not suggest infection. In 29 patients (group 1), stone removal was accomplished during the first session, while for 16 patients (group 2), a nephrostomy tube remained in place and stone removal occurred 3 to 5 days later when results of urine and nephrostomy fluid cultures were negative. We studied preoperative findings, stone-free rate, intraoperative and postoperative complications, and final outcome of these patients. RESULTS: The stone-free rate was almost similar in the two groups (86.2% v 81.25%, P = 0.9). In groups 1 and 2, three (10.3%) and two (12.5%) patients experienced low-grade fever for 12 to 24 hours (P = 0.179). In group 1, urine cultures revealed Escherichia coli in three patients and Pseudomonas aeruginosa in two patients, while 24 (82.7%) patients had negative fluid cultures. In group 2, results of urine cultures showed E coli in two patients and Klebsiella pneumoniae in one patient; results of urine cultures of 13 (81.2%) patients were negative (P = 0.78). Mean operative time was 70 minutes in both groups. No intraoperative or postoperative complications other than fever were seen in both groups. CONCLUSION: In patients who undergo PCNL, purulent fluid may be found incidentally in the puncture site. PCNL may be performed with full antibiotic coverage at the same session.